Three main types of hysterectomy are now used: AH, VH and LH. However, the most important issue in the approach to these surgeries is not the technique per se, but the guidelines in the clinical decision-making process. The SPRS practice guidelines comply with recommendations of the ACOG, which indicate that the route of hysterectomy should be based on surgical indication, the patient's anatomic condition, relevant data, informed patient preference and the surgeon's training and experience. However, in reality, physicians are expected to adopt evidence-based practice guidelines that are cost effective and defined by outcomes rather than physician preference or experience.
In benign conditions, AH should be adopted only when pathological circumstances and the patient's characteristics preclude the vaginal and/or laparoscopic route.[2,37–39] The hysterectomy via abdominal route has traditionally been chosen when the uterus was too big (>12 weeks) or the vagina too narrow, when there was little or no uterus descent and when severe intra-abdominal conditions were suspected owing to previous pelvic surgery (Caesarean section included), adhesions, endometriosis or adnexal disease. It is essential that all these circumstances are evaluated but, in reality, many of them have never been sufficiently analyzed. Fortunately, since the arrival of laparoscopic surgery, the majority of these vaginal contraindications can be resolved with laparoscopy. Thus, previous pelvic surgery or any extrauterine disease (adhesions, adnexal pathology) no longer pose a problem to less invasive routes. When VH is not possible, LS is preferable to AH, although it involves a higher chance of bladder or ureter injury, usually related to the learning curve.
Vaginal hysterectomy should be the standard procedure for removing the uterus in most of the patients.[32,41,42] A significantly faster return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) endorse VH as a preferable option to AH, whenever possible.
Surgical morbidity and associated morbidity are much lower with VH than with AH (3.2 and 0.9% vs 6.2 and 4%, respectively). In a randomized, controlled trial comparing the three methods of hysterectomy, the abdominal technique required an extra day in hospital and an extra week of convalescence. VH was regarded to be the most cost effective of all three types of surgery. Furthermore, VH was the best approach for obese patients and elderly patients with comorbidity.
Currently, a real ratio of VH/AH varies between 1:3 and 1:4 or less, depending on the country, but as explained previously, the adequate training of medical teams could turn this ratio around to 1:8–1:15.[25,45,46]
Previous pelvis surgery, usually in the form of a Caesarean section, does not preclude the vaginal route. Obviously, in this situation, the major concern is the risk of injury to the bladder and the difficult entry into the peritoneum through a scarred anterior pouch. An examination under anesthesia and a diagnostic laparoscopy can help to clarify such doubts surrounding the most appropriate indication for surgery.
Vaginal hysterectomy involves two important and sometimes difficult technical steps: entrance through the peritoneum into the two vaginal cul de sacs and examination of all the uterine attachments. The performance of bilateral salpingo-oophorectomy and uterus morcellation are further procedures that may need to be performed.
Bilateral salpingo-oophorectomy is usually a contraindication for VH, as it can be technically difficult, especially in postmenopausal women. However, it can be successful if the correct technique is employed. In order to provide easy access to the infundibulo–pelvic ligament, the round ligament above the broad ligament must be separately clamped, cut and ligated as far away from the uterus as possible. A specially devised clamp (e.g., a Sheth's adnexa clamp or similar) is applied above the round ligament stump to include the full length of the infundibulo–pelvic ligament. Other systems can be employed if anatomical difficulties are present, including the endoloop suture, a modern sealing system. In a prospective study that evaluated oophorectomies performed during VH, a 97.5% success rate was achieved using these techniques.
Uterus morcellation can be a challenge, often because of the use of inappropriate techniques. The ACOG's 1989 guidelines for choosing the appropriate route for a hysterectomy state that the choice "depends on the patient's anatomy and the surgeon's experience" and that the operation is usually accomplished in women with mobile uteri that are not larger than those at 12 weeks of gestation (280 g).[30,39] As the normal size of a uterus is less than that at 12 weeks gestation, it is usually enough to simply pull in order to deliver it. However, although a uterus at more than 13 weeks gestation can also be easily removed through the vagina, the procedure can be complicated. To overcome these problems, various complementary methods have been described that permit progressive reduction of the volume of the uterus during surgery, such as myomectomy, morcellation, corporal bisection and intramyometrial coring (Figure 1). Once uterine arteries have been sutured, blood supply to the uterus is dramatically diminished (~75–80%), allowing a safe morcellation without blood loss.[48,49] Successful large uterus VHs (>1000 g) have been reported employing these techniques. Unger reported that vaginal removal of large uteri (200–700 g) with respect to uteri with volumes less than 200 g is not associated with an increase in complications or length of hospital stay but only with the duration of the operation, which increases directly in proportion to uterine weight. In recent years, several authors have combined VH with laparoscopic assistance in such circumstances without observing any advantages over the standard vaginal route.
The role of LH remains difficult to define, in spite of the extensive scientific evidence available. Its ultimate aim is to reduce the rate of AH rather than that of VH. Initially, laparoscopy management was devised in order to assist VH in the case of absolute/relative contraindications, such as adhesion, Caesarean scars, adnexectomy and lymphadenectomy. However, a complete laparoscopic performance of the hysterectomy has evolved over time. LH shortens hospital stay, induces less postoperative pain and allows quicker recovery, all at the expense of a longer operation time. LH carries a higher risk of injury to adjacent organs, but may be cost effective, despite higher direct costs, because of the shorter hospital stay and quicker recovery.
One of the most important 'advantages' of the introduction of laparoscopic surgery into gynecology training is that it increases surgeons' confidence and their vaginal surgery skill, making VH a more feasible option. This has played an important role in reducing the number of AHs, as many surgeons feel more comfortable removing via the vaginal route.
In LH, at least part of the operation is performed laparoscopically. This method requires a longer learning curve and greater surgical skills than the vaginal and abdominal methods. The rate of hysterectomies performed laparoscopically is gradually increasing owing to the advantages it affords. It allows a clear view of all pelvic and abdominal structures and facilitates pelvic disease management (e.g., adhesions and endometriosis). In addition, it can be of assistance in adnexal surgery and in checking for pelvis hemostasis once surgery has terminated, and it is characterized by less pain and a rapid recovery time.
The wide variety of techniques employed makes it difficult to carry out a relevant comparison of different reports (or even the results of the same study). As the laparoscopic technique has many particularities, a simple classification has been proposed by which three subcategories are distinguished (Box 2).[52,54] The laparoscopic-assisted VH (LAVH) is performed partly laparoscopically and partly vaginally but the laparoscopic component does not involve uterine vessel ligation. In uterine vessel ligation LH, although the uterine arteries are managed laparoscopically, a part of the operation is performed vaginally (vaginal suture and colpotomy.). In total LH, the whole operation is performed laparoscopically, thus requiring great endoscopic surgical skill.
Endometriosis is one of the major indications for LH, as the technique makes it easier to remove peritoneal or adnexal endometriosis implants by means of different systems (excision, coagulation or vaporization). Endoscopy offers surgeons a magnified view of the pelvis, with close-up images of the pouch of Douglas, ovarian fossa and visceral and parietal peritoneum that are much clearer than those obtained during a laparotomy.
A large uterus is another indication for laparoscopy, as uterine fibroids are a common relative contraindication for VH. Although vaginal morcellation can be achieved with the previously mentioned techniques, it also can be performed laparoscopically with modern laparoscopic morcellators. This management approach can be slow, but it is efficient and safe.
As expected, LH has been extensively analyzed and compared with other techniques. The literature contains four randomized control trials comparing VH with LH.[37,55–57] LH was constantly associated with longer operation times than VH, but with no differences in hospital stay, postoperative pain sensation or postoperative recovery. In total, 12 randomized, controlled trials compared LH with AH,[3,57–67] and all confirmed the advantages of the former, describing similar overall complications but less blood loss, fewer transfusions, less pain, shorter hospital stays, lower levels of disability and better QoL. One of the disadvantages of LH was the longer operating times reported for the endoscopic procedure.[68–70] When endoscopic skills are adequate, total LH can be quicker, more efficient and associated with less blood loss than LAVH, particularly in nulliparous or obese patients.[71,72] Although not strictly necessary, one of the more important steps of this technique is the use of an intrauterine manipulator, which mobilizes the uterus in all directions to create space in the working field and facilitate dissection and colpotomy. This instrument significantly reduces the operating time and complication rate (usually vesical and ureteral injury) and permits a more reproducible technique. Uterine manipulators should not be employed in cases of endometrial malignancy, as it can increase the hypothetical risk of vaginal relapse.
The learning curve is also a relevant factor in LH. This is a difficult aspect to study, and is usually discussed in terms of operation time, conversion and complication rate. The aforementioned laparoscopic skills of the surgeon determine the length of the curve. The Finnish registry demonstrated that the experience of the surgeon was directly related to the occurrence of major complications; it highlighted that, after 30 LHs, bladder and ureter injuries were far less frequent.
There are no absolute contraindications for laparoscopy, and relative circumstances are usually related to general anesthesia and hypothetical problems in the abdomen entry. Morbid obesity (BMI > 30) is often a challenge when establishing the pneumoperitoneum. Previous abdominal scars, especially midline incisions, increase the risk of abdominal adhesions and can make abdominal entry and surgery difficult, leading to a major incidence of bowel lesions. In the majority of cases, uterine size is not a contraindication, as modern endoscopic morcellation facilitates the removal of the uterus. A more transcendental aspect is uterine mobility, as a fixed uterus is a challenge to the laparoscopic approach and to any route.
Robotics is a new step in laparoscopy and LH, and has been implanted in many centers since 2001. It offers all the benefits of the laparoscopic approach with several key differences: the instruments constitute an articulating wrist that mimics the movements of the human hand, it affords 3D vision and the usual hand trembling that occurs when performing delicate movements is avoided. The seven degrees of freedom of the articulating wrist make it easier to work in the deep pelvis, and it performs perfect movements when suturing, excising and reconstructing tissue. Little evidence concerning robotic hysterectomy has been published to date, but reports that favor this approach are beginning to appear.[75,76] This approach offers the patient another minimally invasive option in addition to laparoscopy or VH.
Expert Rev of Obstet Gynecol. 2009;4(6):673-685. © 2009 Expert Reviews Ltd.
Cite this: Overview of Current Trends in Hysterectomy - Medscape - Nov 01, 2009.